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Bipolar Disorder

This leaflet is for anyone who wants to know
more about bipolar disorder (sometimes called bipolar affective
disorder or manic depression). It is especially helpful for anyone
who has bipolar disorder, their friends and relatives. Many
patients prefer the term ‘bipolar’ rather than ‘bipolar disorder’
as they have an illness not a disorder.

This leaflet describes:

the disorder

some of the problems it can create

ways of coping

some of the treatments available.

What is bipolar disorder?

Bipolar disorder used to be called ‘manic
depression’. As the older name suggests, someone with bipolar
disorder will have severe mood swings. These usually last several
weeks or months and are far beyond what most of us experience. They
are:

Low or 'depressive'

feelings of
intense depression and despair

High or 'manic'

feelings of
extreme happiness and elation

Mixed

for example, depressed mood with the restlessness and
overactivity of a manic episode

How common is bipolar disorder?

About 1 in every 100 adults has bipolar
disorder at some point in their life. It usually starts between the
ages of 15 to 19 - and it rarely starts after the age of 40.
Men and women are affected equally.

What types are there?

Bipolar I

If you have had at least one high or manic
episode, which has lasted for longer than one week.

You may only have manic episodes,
although most people with Bipolar I also have periods of
depression.

Untreated, a manic episode
will generally last 3 to 6 months.

Depressive episodes last rather longer - 6 to
12 months without treatment.

Bipolar II

If you have had more than one episode of
severe depression, but only mild manic episodes – these are called
‘hypomania’.

Rapid cycling

If you have more than four mood swings in a
12 month period. This affects around 1 in 10 people with bipolar
disorder, and can happen with both types I and II.

Cyclothymia

The mood swings are not as severe as those in
full bipolar disorder, but can be longer. This can develop into
full bipolar disorder.

What causes bipolar disorder?

We don't understand this well, but research
suggests that:

Bipolar disorder runs in families - it seems
to have more to do with genes than with upbringing.

There may be a physical problem with the
brain systems which control our moods - this is why bipolar
disorder can often be controlled with medication.

But - mood swings can be brought on by
stressful experiences or physical illness.

What does it feel like?

This depends on which way your mood has swung.

Depression

The feeling of depression is something we all
experience from time to time. It can even help us to recognise and
deal with problems in our lives. In clinical depression or
bipolar disorder, the feeling of depression is much worse. It goes
on for longer and makes it difficult or impossible to deal with the
normal things of life. If you become depressed, you will notice
some of these changes:

Emotional

feelings of unhappiness that don't go
away

feeling that you want to burst into tears for
no reason

losing interest in things

being unable to enjoy things

feeling restless and agitated

losing self-confidence

feeling useless, inadequate and hopeless

feeling more irritable than usual

thinking of suicide.

Thinking

can’t think positively or hopefully

finding it hard to make even simple
decisions

difficulty in concentrating.

Physical

losing appetite and weight

difficulty in getting to sleep

waking earlier than usual

feeling utterly tired

constipation

going off sex.

Behaviour

difficulty in starting or completing things –
even everyday chores

crying a lot – or feeling like you want to
cry, but not being able to

avoiding contact with other people.

Mania

You have an intense sense of well-being,
energy and optimism. It can be so strong that it affects your
thinking and judgement. You may believe strange things about
yourself, make bad decisions, and behave in embarrassing, harmful
and - occasionally - dangerous ways.

Like depression, it can make it difficult or
impossible to deal with day-to-day life. Mania can
badly affect both your relationships and your work. When it
isn't so extreme, it is called 'hypomania'.

If you become manic, you may notice that you
are:

Emotional

very happy and excited

irritated with other people who don't share
your optimistic outlook

feeling more important than usual.

Thinking

full of new and exciting ideas

moving quickly from one idea to another

hearing voices that other people can't
hear.

Physical

full of energy

unable or unwilling to sleep

more interested in sex.

Behaviour

making plans that are grandiose and
unrealistic

very active, moving around very quickly

behaving unusually

talking very quickly - other people may find
it hard to understand what you are talking about

making odd decisions on the spur of the
moment, sometimes with disastrous consequences

recklessly spending your money

over-familiar or recklessly critical with
other people

less inhibited in general.

If you are in the middle of a manic episode
for the first time, you may not realise that there is anything
wrong – although your friends, family or colleagues will. You may
even feel annoyed if someone tries to point this out to you.
You increasingly lose touch with day-to-day issues – and with other
people's feelings.

Psychotic symptoms

If an episode of mania or depression becomes very severe, you
may develop psychotic symptoms.

In a manic episode - these will tend to be
grandiose beliefs about yourself - that you are on an important
mission or that you have special powers and abilities.

In a depressive episode - that you are
uniquely guilty, that you are worse than anybody else, or even that
you don't exist.

As well as these unusual beliefs, you might experience
hallucinations - when you hear, smell, feel or see something, but
there isn't anything (or anybody) there to account for
it.

Between episodes

Some people can get back to normal in between their mood swings.
But this is not so for many people with bipolar disorder. You may
continue to experience mild depressive symptoms and problems in
thinking, even when you seem to be better.

Bipolar disorder may result in you having to stop driving for a
while. Visit the DVLA
website for further information.

Treatments

There are some things you can try to control
mood swings so that they stop short of becoming full-blown episodes
of mania or depression. These are mentioned below, but medication
is still often needed to:

keep your mood stable (prophylaxis)

treat a manic or depressive episode.

Medications to stabilise mood

There are several mood stabilisers, some of
which are also used to treat epilepsy or schizophrenia. Your
psychiatrist may need to use more than one medication to control
mood swings effectively.

Lithium

Lithium has been used as a mood stabiliser for 50 years – but
how it works is still not clear. It can be used to treat both manic
and depressive episodes.

Treatment with Lithium should be started by a psychiatrist. The
difficulty is getting the level of Lithium in the body right – too
low and it won't work, too high and it becomes toxic. So, you will
need regular blood tests in the first few weeks to make sure that
you are getting the right dose. Once the dose is stable, your GP
can prescribe your Lithium and arrange the regular blood tests.

The amount of Lithium in your blood is very sensitive to how
much, or how little, water there is in your body. If you become
dehydrated, the level of Lithium in your blood will rise, and you
will be more likely to get side-effects, or even toxic effects. So,
it’s important to:

drink plenty of water – more in hot weather or when you are
active

be careful with tea and coffee - they increase the amount of
water you pass in your urine.

It can take three months or longer for Lithium to work properly.
It's best to carry on taking the tablets, even if your mood swings
continue during this time.

Side-effects

These can start in the first few weeks after starting Lithium
treatment. They can be irritating and unpleasant, but often
disappear or get better with time.

They include:

feeling thirsty

passing more urine than usual

weight gain.

Less common side-effects are:

blurred vision

slight muscle weakness

occasional diarrhoea

fine trembling of the hands

a feeling of being mildly ill.

These can usually be improved by lowering the
dose of Lithium.

The following signs suggest that your Lithium
level is too high. Contact your doctor immediately if you
notice:

you feel very thirsty

you have bad diarrhoea or vomiting

obvious shaking of your hands and legs

twitching of your muscles

you get muddled or confused.

Blood tests

At first you will need blood tests every few
weeks to make sure that you have the right level of Lithium in your
blood. You will need these tests for as long as you take Lithium,
but less often after the first few months.

Long-term use of Lithium can affect the
kidneys or the thyroid gland. It is wise to have blood tests every
few months to make sure that they are working properly. If there is
a problem, you may need to stop Lithium and consider an
alternative.

Taking care of yourself

Watch out for caffeine – in tea, coffee or
cola. This makes you urinate more, and so can upset your Lithium
level.

Other mood stabilisers

There are other medications, apart from Lithium, that can
be used to help.

Anti-epileptic
medications/anticonvulsants: it is possible that Sodium
Valproate, an anti-convulsant, works just as well Lithium, but we
don’t yet have enough evidence to be sure. It should not be
prescribed to women of child-bearing age.

Carbamazepine and
Lamotrigine are also effective for some people.

Antipsychotic medications:
Olanzapine or Quetiapine.

What is the best treatment for me?

You need to discuss this with your doctor, but
some general principles are:

Lithium, Sodium Valproate and Olanzapine will
usually be recommended for long-term treatment.

Carbamazepine may be suggested if you have
faster and more frequent mood swings.

Lamotrigine may be suggested for bipolar II disorder.

Sometimes a combination of drugs is
needed.

Much depends on how well you get on with a
particular medication. What suits one person may not suit another,
but it makes sense to first try the medications for which there is
better evidence.

What will happen without medication?

Lithium reduces your chance of relapse by
30–40%, but the more manic episodes you’ve had, the more likely you
are to have another one.

Number of previous manic episodes

Chance of having another episode in
the next year

Not taking Lithium

Taking Lithium

1-2

10% (10 in 100)

6-7% (6-7 in 100)

3-4

20% (20 in 100)

12% (12 in 100)

5+

40% (40 in 100)

26% (26 in 100)

As you get older, the risk of getting further
episodes stays much the same. Even if you have been well for a long
time, you still run the risk of having another episode.

When to start a mood stabiliser

After just one episode, it’s difficult to
predict how likely you are to have another. You may not want to
start medication at this stage – unless your episode was very
severe and disruptive.

If you have a second episode, there is a
strong chance of further episodes – so most psychiatrists would
usually recommend a mood stabiliser at this point.

For how long should a mood stabiliser be continued?

For at least two years after one episode of
bipolar disorder, and for up to five years if there have been:

frequent previous relapses

psychotic episodes

alcohol or substance misuse

continuing stress at home or at work.

If you continue to have troublesome mood
swings, you may need to continue medication for longer.

Pregnancy

You should discuss any pregnancy plans with
your psychiatrist. Together, you can arrange how to manage your
mood during the pregnancy and for the first few months after the
baby arrives.

If you are pregnant, it's best to discuss with
your psychiatrist whether or not to stop Lithium. Although Lithium
is safer in pregnancy than the other mood stabilisers, the risk to
the baby needs to be weighed against the risk of you becoming
depressed or manic. The risk is greatest during the first three
months of pregnancy. Lithium is safe after the 26th week of
pregnancy, although you should not breastfeed your baby if you are
taking Lithium.

During pregnancy, everyone involved - the
obstetrician, midwives, health visitors, GP, psychiatrist, and
community psychiatric nurse – need to stay in close touch with each
other.

Treating a manic or depressive episode

Depressive episodes

If your depression is moderately severe, your doctor may
well recommend an SSRI
antidepressant.

If you are already on Lithium or Sodium Valproate, then
sometimes adding Quetiapine can help.

If you have had a recent manic episode or have a rapid-cycling
disorder, an antidepressant may push you into a manic swing. It may
be safer to increase the dose of the mood stabiliser, without an
antidepressant.

Antidepressants can take between 2 and 6 weeks to improve your
mood, but sleep and appetite often improve first. Antidepressants
should be continued for at least 8 weeks after the depression has
improved, and then consider stopping them by tailing off the dose
slowly.

If you have repeated depressive episodes, but have never
switched to mania on antidepressants, you can continue on both a
mood stabiliser and an antidepressant to prevent further
episodes.

If you have had manic episodes, you should not continue
antidepressants long-term.

Mania and mixed depressive episodes

Any antidepressant should be stopped. Lithium,
Sodium Valproate, Olanzapine, Quetiapine or Risperidone are most
often used to treat a manic episode.

Once the treatment has started, symptoms
usually improve within a few days, but it may take several weeks
for a full recovery. You should check with your doctor if you
want to drive while taking this sort of medication.

Other help: If you run
into trouble from, say, spending too much when you are high, your
mental health team will help you to negotiate with your bank or
people you owe money to. If this has happened, it may be worth
thinking about giving power of attorney over your affairs to a
carer or relative whom you trust.

Stopping the mood swings - helping
yourself

Self-monitoring

Learn how to recognise the signs that your
mood is swinging out of control so you can get help early. You may
be able to avoid both full-blown episodes and hospital admissions.
Keeping a mood diary can help to identify the things in your life
that help you – and those that don't.

Try to avoid particularly stressful situations
- these can trigger off a manic or depressive episode. It's
impossible to avoid all stress, so it may be helpful to learn ways
of handling it better. You can do relaxation training with CDs or
DVDs, join a relaxation group, or seek advice from a clinical
psychologist.

Relationships

Depression or mania can cause great strain on
friends and family - you may have to rebuild some relationships
after an episode.

It's helpful if you have at least one person
that you can rely on and confide in. When you are well, try
explaining the illness to people who are important to you. They
need to understand what happens to you - and what they can do for
you.

Activities

Try to balance your life and work, leisure,
and relationships with your family and friends. If you get too busy
you may bring on a manic episode.

Make sure that you have enough time to relax
and unwind. If you are unemployed, think about taking a course, or
doing some volunteer work that has nothing to do with mental
illness.

Exercise

Reasonably intense exercise for 20 minutes or
so, three times a week, seems to improve mood.

Fun

Make sure you regularly do things that you
enjoy and that give your life meaning.

Continue with medication

You may want to stop your medication before
your doctor thinks it is safe – unfortunately this often leads to
another mood swing. Talk it over with your doctor and your family
when you are well.

Have your say in how you are
treated

If you have been admitted to hospital for bipolar disorder, you
may want to write an ‘advance directive’ with your doctor and
family to say how you want to be treated if you become ill
again.

What can I expect from my GP? (England & Wales only)

If you are taking Lithium or any other
medication for your bipolar disorder, your GP is now expected to
give you an annual physical health check. This will check your:

a blood pressure

weight

smoking and alcohol use

blood sugar levels

lipid levels - for all patients over the age of 40.

If you are taking Lithium, you will need a
Lithium level check every 3-6 months, and a blood test for thyroid
and kidney function at least every 15 months.

Advice for family and friends

Mania or depression can be distressing – and
exhausting - for family and friends.

Dealing with a mood episode

Depression

It can be difficult to know what to say to
someone who is very depressed. They see everything in a negative
light and may not be able to say what they want you to do. They can
be withdrawn and irritable, but at the same time need your help and
support. They may be worried, but unwilling or unable to accept
advice. Try to be as patient and understanding as
possible.

Mania

At the start of a manic mood swing, the person
will appear to be happy, energetic and outward-going - the ‘life
and soul’ of any party or heated discussion. However, the
excitement of such situations will tend to push their mood even
higher. So try to steer them away from such situations. You can try
to persuade them to get help, or get them information about the
illness and self-help.

Practical help is very important – and much
appreciated. Make sure that your relative or friend is able to look
after themselves properly.

Helping your loved ones stay well

In between mood episodes, find out more about
bipolar disorder. It may be helpful to go with your friend or loved
one to any appointments with the GP or psychiatrist.

Staying well yourself

Give yourself space and time to recharge your
batteries. Make sure that you have some time on your own, or with
trusted friends who will give you the support you need. If your
relative or friend has to go into hospital, share the visiting with
someone else. You can support your friend or relative better if you
are not too tired.

Dealing with an emergency

In severe mania, a person can become hostile,
suspicious and verbally or physically explosive.

In severe depression, a person may start to
think of suicide.

If you find that they are:

seriously neglecting themselves by not eating
or drinking

behaving in a way that places them, or
others, at risk

talking of harming or killing themselves

Get medical help
immediately.

Keep the name of a trusted professional (and
their telephone number) for any such emergency. A short admission
to hospital may sometimes be needed.

Looking after children

If you become manic or depressed, you may
temporarily not be able to look after your children properly. Your
partner, or another family member, will need to organise the
children's care while you are unwell. It can be helpful to make
plans for this in advance when you are well.

You may find that your child may feel anxious
and confused when you are not well. If they cannot express their
distress in words, toddlers can become difficult or clingy, and
older children will show it in other ways.

Children will find it helpful if the adults
around them are sensitive, understanding, and can respond to their
difficulties in a calm, consistent and supportive way. Adults can
help them to understand why their parent is behaving differently.
Questions will need to be answered calmly, factually and in
language they can understand. They will feel better if they can
keep to their usual daily routine.

Explaining bipolar disorder to children

Older children may worry that they have caused
the illness – that it is their fault. They need to be reassured
that they are not to blame, but also to be shown what they can do
to help. When an older child takes responsibility for caring for a
sick parent, they will need particular understanding and practical
support.

Support groups and caring organisations

Tel: 0141 560 2050. Provides information,
support and advice for people affected by bipolar disorder and all
who care for them. Promotes self-help throughout Scotland, and
informs and educates about the illness and the organisation.

Tel: 0845 123 23 20; email: information@depressionalliance.org.
Information, support and understanding for people who suffer with
depression, and for relatives who want to help. Self-help groups,
information, and raising awareness for depression.

A range of materials for carers of people with mental health
problems has also been produced by the Partners in Care campaign.
These can be downloaded from www.partnersincare.co.uk

For
a catalogue of public education materials or copies of our leaflets
contact: Leaflets
Department, The Royal College of Psychiatrists, 21
Prescot Street, London E1 8BB. Telephone: 020
7235 2351 x 2552

Charity registration number (England and Wales) 228636
and in Scotland SC038369.

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Please note that we are unable to offer advice on individual cases. Please see our
FAQ for
advice on getting help.

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